危重病患者早期肠内营养预防应激性溃疡的观察及护理

目的 :验证早期肠内营养对重症患者应激性溃疡的预防作用 ,并对这类患者的护理注意事项进行探讨。方法 :对 77例进ICU的危重患者随机分成早期肠内营养组 (42例 )和延迟肠内营养组 (35例 ) ,分别对每例患者的胃液及粪便进行不同时间段的隐血情况监测 ,并对监测结果进行统计学处理。结果 :早期肠内营养组与延迟肠内营养组上消化道出血发生分别为 4 / 4 2和 15 / 35例 (P <0 .0 0 1)。结论 :早期肠内营养对危重患者应激性溃疡的发生有一定的预防作用。     

危重病患者早期肠内营养应激性溃疡的预防及护理

目的 :验证早期肠内营养对重症患者应激性溃疡的预防作用 ,并总结临床护理经验。方法 :随机将入院ICU的危重患者 77例分成早期肠内营养组 (4 2例 )和延迟肠内营养组 (35例 ) ,分别监测每例患者不同时间段的胃液及粪便的隐血情况 ,并对监测结果进行统计学处理。结果 :早期肠内营养组与延迟肠内营养组上消化道出血发生分别为 4 / 4 2和 15 / 35 (P <0 0 0 1)。结论 :早期肠内营养对危重患者应激性溃疡的发生有一定的预防作用。     

Survey of stress ulcer prophylaxis

Background  

No surveys of stress ulcer prophylaxis prescribing in the USA havebeen conducted since 1995. Since that time, the most comprehensive meta-analysisand largest randomized study to date concerning stress ulcer prophylaxis havebeen published.     

Ranitidine--bolus or infusion prophylaxis for stress ulcer

Stress ulcer is a dangerous complication for the critically ill patient. Prophylaxis with antacids can undoubtedly reduce this risk, if gastric pH is maintained above 3.5. Histamine receptor antagonists may achieve this more conveniently. We have studied the effects of ranitidine, given either as 50-mg boluses every 6 h or as one of two infusion regimes (125 or 250 micrograms/kg.h), in controlling pH in critically ill patients on a ventilator. The percentage of samples with a pH less than 4 fell in all groups during therapy; while there was no significant difference between groups, pH control was achieved more rapidly in the bolus group. Infusion therapy with ranitidine is an attractive concept but a loading dose must be used. The presence of occult blood in the gastric juice did not correlate with pH and was not affected by ranitidine therapy.     

A cost-effectiveness analysis of stress ulcer prophylaxis

OBJECTIVE: To evaluate the efficacy, safety, and cost of using cimetidine, famotidine, and lansoprazole for stress ulcer prophylaxis (SUP) at our institution and determine which agent was most cost-effective. METHODS: An observational study of adults admitted to the medical, surgical, or cardiovascular intensive care unit was conducted to compare the cost and effectiveness of cimetidine, famotidine, and lansoprazole for SUP. Patients were identified for inclusion during three 2-week periods in 2000. Medical record reviews were conducted to gather data regarding the costs associated with the administration of SUP drugs and the treatment of any adverse events or therapeutic failures. Decision analysis was used to determine the average cost per patient for each treatment arm. A cost-effectiveness analysis was then conducted to determine which of the SUP agents was associated with the least cost without adversely affecting patient outcomes. A sensitivity analysis was applied to determine the robustness of the data. RESULTS: Eighty-eight patients were included in the analysis. Five of the patients started on cimetidine experienced therapeutic failure, whereas no patients receiving lansoprazole experienced therapeutic failure. For these reasons, and because lansoprazole is an oral agent, the average costs associated with lansoprazole use were lower than with the use of cimetidine. Lansoprazole was found to be the most cost-effective therapy. CONCLUSIONS: This study showed that lansoprazole is a cost-effective agent for the use of SUP at our institution. However, due to the higher cost of intravenous pantoprazole, the model demonstrates that, assuming equal effectiveness, intravenous pantoprazole would not be cost-effective when compared with cimetidine.     

Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients

OBJECTIVE: To evaluate the use of proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in critically ill adults. DATA SOURCES: Computerized biomedical literature search of MEDLINE (1966-June 2002) was conducted using the MeSH headings proton-pump inhibitor, ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts. DATA SYNTHESIS: Traditional medications used for stress ulcer prophylaxis include antacids, histamine(2) receptor antagonists (H(2)RAs), and sucralfate. Few studies have evaluated PPIs for stress ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH > or =4.0. PPIs are safe and seem to be as efficacious as H(2)RAs or sucralfate for prevention of bleeding from stress-related mucosal damage (SRMD) and they may provide cost minimization. The small patient populations limit the results of comparative studies. CONCLUSIONS: Available data indicate that PPIs are safe and efficacious for elevating intragastric pH in critically ill patients. PPIs should be used only as an alternative to H(2)RAs or sucralfate since the superiority of PPIs over these agents for preventing SRMD-associated gastrointestinal bleeding has not been established. Additional comparative studies with adequate patient numbers and pharmacoeconomic analyses are needed before PPIs are considered the agents of choice for stress ulcer prophylaxis.     

早期肠内营养对预防重型颅脑损伤应激性溃疡的效果研究

目的 探讨早期胃肠内营养对重型颅脑损伤患者应激性溃疡的影响.方法 选择重型颅脑损伤患者134例,随机分为2组,早期肠内营养组(EEN组)69例在入院或术后24 h内插管鼻饲进食,延迟肠内营养组(DEN组)65例在术后24 h后插管鼻饲进食.比较2组患者发生上消化道出血情况.结果 EEN组上消化道出血率明显低于DEN组.结论 重型颅脑损伤患者尽早实施胃肠内营养,可以减轻应激性溃疡的发生,预防上消化道出血.     

肠内营养辅助治疗压疮效果的荟萃分析

[目的]系统评价肠内营养辅助治疗压疮的效果,为指导压疮病人合理补充营养提供循证依据。[方法]使用压疮治疗肠内营养相关的中英文关键词,检索Cochrane图书馆、JBI系统评价数据库、MEDLine、(Web of Science)、EMbase、CBMdisc、CNKI和万方数据库中相关的随机对照试验,同时筛检纳入文献的参考文献。由3名研究者按纳入和排除标准独立筛选并对文献质量进行严格评价和资料提取,对符合质量标准的文献采用RevMan5.0软件进行Meta分析。[结果]共纳入9篇随机对照试验共计793例病人(试验组397例,对照组396例),Mate分析结果显示肠内营养可缩小压疮面积[SMD为-0.93,95%CI(-1.40,-0.46)]、减少压疮的愈合计分,对压疮愈合有促进作用;但不能增加压疮病人的治愈率[RR为1.46,95%CI(1.00,2.12)],同时不会增加压疮病人的不良反应发生率[RR为1.12,95%CI(0.38,3.31)],表明肠内营养剂是安全的。[结论]肠内营养支持能缩小压疮面积和促进压疮愈合,不能提高压疮治愈率。但由于样本量有限,还需高质量、大样本的随机对照试验予以进一步验证。     

Pulmonary complications from enteral nutrition.

Complications of enteral nutrition may compromise respiratory function by direct mechanical injury by feeding tubes, aspiration of formula, or alterations in metabolism. Although much of the data reviewed in this paper were published more than 10 years ago, these studies still comprise most of the literature on pulmonary complications of enteral nutrition. Many of the products that are described in these older studies no longer exist or are not widely used. Additional research is needed to determine whether the enteral formulas and delivery devices that have recently been developed are associated with a similar incidence of misplacement, aspiration, or displacement as that previously reported.     

Percutaneous endoscopic gastrostomy. Simplified access for enteral nutrition

The recently described technique of endoscopic placement of a permanent feeding gastrostomy is reviewed with several modifications. Our experience in 23 adults has led us to conclude that this nonsurgical technique is the procedure of choice in achieving long-term enteral nutrition in patients who have an intact, nonobstructed gut and in whom the stomach can be directly apposed to the anterior abdominal wall.     

改良肠内营养输注法对危重病人肠内营养并发症的影响

[目的]观察改良肠内营养(EN)输注方法对危重病人肠内营养并发症的影响。[方法]将入住重症监护病房(ICU)的82例肠内营养时间>3d的危重病人,采用随机数字表法分为两组,实验组采用改良输注方法,对照组应用传统持续输注方法(不间断)。两组每天肠内营养量均为1 000mL～1 500mL,12h～24h输完,使用加温器保持营养液温度37℃～41℃,分别观察两组病人肠内营养的各种并发症,并进行两组间比较。[结果]两组胃肠道症状、食物反流、胃管堵塞、应激性溃疡、吸入性肺炎发生率比较,实验组明显低于对照组(P<0.05);两组代谢方面的并发症发生率差异无统计学意义(P>0.05)。[结论]改良肠内营养持续输注方法可以降低危重病人肠内营养并发症的发生。     

改良肠内营养输注法对危重病人肠内营养并发症的影响

[目的]观察改良肠内营养（EN）输注方法对危重病人肠内营养并发症的影响。[方法]将入住重症监护病房（ICU）的82例肠内营养时间〉3d的危重病人,采用随机数字表法分为两组,实验组采用改良输注方法,对照组应用传统持续输注方法（不间断）。两组每天肠内营养量均为1 000mL～1 500mL,12h～24h输完,使用加温器保持营养液温度37℃～41℃,分别观察两组病人肠内营养的各种并发症,并进行两组间比较。[结果]两组胃肠道症状、食物反流、胃管堵塞、应激性溃疡、吸入性肺炎发生率比较,实验组明显低于对照组（P〈0.05）;两组代谢方面的并发症发生率差异无统计学意义（P〉0.05）。[结论]改良肠内营养持续输注方法可以降低危重病人肠内营养并发症的发生。     

Delivery of enteral nutrition

There is increasing evidence that enteral feeding is superior to parenteral nutrition with regard to maintaining gut structure and function. Selection of the enteral access route depends on the type and anticipated duration of nutrient delivery. At present, enteral feeding devices can be divided into two major categories: those entering the gastrointestinal tract through the oral or nasal cavity (oroenteric or nasoenteric tubes) and those entering through the abdominal wall including gastrostomy, duodenostomy, or jejunostomy tubes. This article provides a review of methods to insert and confirm gastric and intestinal feeding tube placement. Care of the patient with an enteric tube will be described.